1. BURNSBURNS
ANDAND
BASICS OF PLASTIC SURGERYBASICS OF PLASTIC SURGERY
DR. ABDUL MAJID BHATDR. ABDUL MAJID BHAT
M.S., F.R.C.S. (ENGLAND)M.S., F.R.C.S. (ENGLAND)
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2. 22

3. 33
BURNSBURNS
DefDef..
it is injury of the tissue caused by extremesit is injury of the tissue caused by extremes
of temperature (heat or cold ) or chemicalsof temperature (heat or cold ) or chemicals
or ionising radiations.or ionising radiations.
Basic pathophysiologyBasic pathophysiology..
 involves two parts as compared to mechanical traumainvolves two parts as compared to mechanical trauma
 physical injury to tissuephysical injury to tissue
 Physiological injury to cells…..charing and precipitationPhysiological injury to cells…..charing and precipitation
of protoplasm of cellof protoplasm of cell
External skin burns are the most commonExternal skin burns are the most common
surgical emergency.surgical emergency.

4. 44
Types and causesTypes and causes
 ThermalThermal due todue to
 FireFire
 Steam, boiling liquids……..calledSteam, boiling liquids……..called SCALDSSCALDS
 Blast, missile and fire arm injuriesBlast, missile and fire arm injuries
 ChemicalsChemicals ……acids, alkalis etc.……acids, alkalis etc.
 Ultravoilet raysUltravoilet rays…..sun burns…..sun burns
 Radiations….nuclear rays, radiation therapyRadiations….nuclear rays, radiation therapy
 Electricity currentElectricity current
 Mechanical friction injuryMechanical friction injury
 Burns commonly involve skin but can involveBurns commonly involve skin but can involve
subcutaneous tissue, muscle and bone even insubcutaneous tissue, muscle and bone even in
severe cases.severe cases.

5. 55
 Skin …structure and functionsSkin …structure and functions
 AnatomyAnatomy
 SizeSize….Largest organ in body…with surface area….Largest organ in body…with surface area 1.7 sq. meters1.7 sq. meters inin
adultadult
 Thickness…….? I do not know !.....any body knows it.Thickness…….? I do not know !.....any body knows it.
 Two layersTwo layers
 EpidermisEpidermis….5 layers of epithelial cells….5 layers of epithelial cells
 DermisDermis….2 layers…contain air follicles, nerve endings, blood….2 layers…contain air follicles, nerve endings, blood
vessels, fibrous tissue, sweat glands, sebaceous glandsvessels, fibrous tissue, sweat glands, sebaceous glands
 FunctionsFunctions
 Identity of a person or race, beautyIdentity of a person or race, beauty
 Physical barrier for microorganismsPhysical barrier for microorganisms
 Sweat glands regulate body temperature, excrete waste products,Sweat glands regulate body temperature, excrete waste products,
hormones, cholesterol, electrolytes, etc.hormones, cholesterol, electrolytes, etc.
 Dermis prevents excessive fluid loss by evaporationDermis prevents excessive fluid loss by evaporation
 Sensory organSensory organ
 Vitamin D synthesisVitamin D synthesis
 Forensic importance……..fingerprintsForensic importance……..fingerprints

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 Factors determining the severity andFactors determining the severity and
prognosis in burnsprognosis in burns
 Depth of burnDepth of burn
 Surface area involvedSurface area involved
 Age of patientAge of patient
 Site of burnSite of burn
 Associated injuriesAssociated injuries
 Type of burnType of burn
 Other associated disease factorsOther associated disease factors

10. 1010
 Depth of burns……classificationDepth of burns……classification
 Three degrees……Three degrees……according to thickness of skinaccording to thickness of skin
involvedinvolved
 Ist degree………..epidermis onlyIst degree………..epidermis only
 Second degree….epidermis and part of dermisSecond degree….epidermis and part of dermis
 Third degree…….epidermis and complete dermisThird degree…….epidermis and complete dermis
Some authors mention 4 th degree burns for involvement of muscle, bone andSome authors mention 4 th degree burns for involvement of muscle, bone and
subcutaneous tissuessubcutaneous tissues
 First degreeFirst degree
 Involve epidermis onlyInvolve epidermis only
 Caused by sunlight or brief scaldingCaused by sunlight or brief scalding
 Tissue damage is minimalTissue damage is minimal
 Pain is predominant symptom as nerve endings getPain is predominant symptom as nerve endings get
exposedexposed
 Burn skin is red erythematous,Burn skin is red erythematous,
 Healing occurs by epithelization in 5-10 daysHealing occurs by epithelization in 5-10 days
 Systemic effects like fluid loss are rareSystemic effects like fluid loss are rare

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 Third degreeThird degree
 Involve epidermis, complete dermis andInvolve epidermis, complete dermis and
extend into deeper tissuesextend into deeper tissues
 Characterized by dry, tough ,leathery surface,Characterized by dry, tough ,leathery surface,
brown or black or whitish in colorbrown or black or whitish in color
 Blisters are absentBlisters are absent
 No painNo pain…..because pain receptors are…..because pain receptors are
destroyeddestroyed
 Tissues are dead and blood vessels areTissues are dead and blood vessels are
thrombosedthrombosed

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First degree burns

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2nd
degree burns with…..blisters,( vesicals)

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Second degree burns

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Which degree burn is it?

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Full thickness 3rd
. degree burns

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 Extent of burn surface…Extent of burn surface…
 ……calculated as percentage of body surface areacalculated as percentage of body surface area
(BSA)(BSA)
 Determined byDetermined by rule of 9rule of 9 in adultsin adults
 Head and neckHead and neck =9%=9%
 Right armRight arm =9%=9%
 Left armLeft arm =9%=9%
 Chest& abdomen frontChest& abdomen front =18%=18%
 Chest & abdomen backChest & abdomen back =18%=18%
 Right lower limbRight lower limb =18%=18%
 Left lower limbLeft lower limb =18%=18%
 TotalTotal =99%=99%
Where is one percent ?Where is one percent ?
 Different formula for children and infants.Different formula for children and infants.

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RULE OF NINE

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 Accurate estimation of burned surfaceAccurate estimation of burned surface
area is very important…because it isarea is very important…because it is
directly related todirectly related to
 severity ,severity ,
 prognosis,prognosis,
 fluid loss,fluid loss,
 metabolic changes andmetabolic changes and
 patient managementpatient management
 Rough estimation……….size of one palm of handRough estimation……….size of one palm of hand
is equal to one % burn……….is equal to one % burn……….palm of patient notpalm of patient not
doctor or nurse…..!doctor or nurse…..!

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3–4%2ND
DEGREE BURN RIGHT ARM

25.  Age of patient….Age of patient….
 Burns of same specific depth and surface areaBurns of same specific depth and surface area
inflict higher morbidity and mortality in infantsinflict higher morbidity and mortality in infants
below two years and elderly people above 60below two years and elderly people above 60
yearsyears
 Infants below 2 years have not well developedInfants below 2 years have not well developed
immune system and have less resistanceimmune system and have less resistance
 Older people above 60 years have otherOlder people above 60 years have other
associated disease factors alsoassociated disease factors also
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26.  Associated disease factorsAssociated disease factors
 Other associated disease factors increaseOther associated disease factors increase
the morbidity and mortality in a burn patientthe morbidity and mortality in a burn patient
as compared to a normal person asas compared to a normal person as
 Pulmonary diseasePulmonary disease
 DiabetesDiabetes
 Congestive heart failureCongestive heart failure
 Immuno -suppresive drugsImmuno -suppresive drugs
 Chronic use of steroidsChronic use of steroids
 Radiation therapyRadiation therapy
 ChemotherapyChemotherapy
 AnaemiaAnaemia
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27.  Site of burnSite of burn
 Burns involving some particular sites haveBurns involving some particular sites have
higher mortality and morbidityhigher mortality and morbidity
 FaceFace
 NeckNeck
 HandsHands
 Perineal areasPerineal areas
 FeetFeet
These are calledThese are called primary areas…..andprimary areas…..and
burns of these areas need hospitalizationburns of these areas need hospitalization
and special care.and special care. 2727

28.  Associated injuriesAssociated injuries
 Other associated injuries along with burnsOther associated injuries along with burns
increase mortality and morbidity asincrease mortality and morbidity as
 Inhalation smoke injuryInhalation smoke injury
 FracturesFractures
 Head injuriesHead injuries
 Chest and thoracic trauma etc.Chest and thoracic trauma etc.
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29.  Type of burnType of burn
 Electrical and chemical burns may appearElectrical and chemical burns may appear
minor externally but may involve moreminor externally but may involve more
damage to deeper tissuesdamage to deeper tissues
 Fire burns may damage more than scaldsFire burns may damage more than scalds
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30.  Management of burn patientManagement of burn patient
Mortality and morbidity can be reduced byMortality and morbidity can be reduced by
 Urgent attentionUrgent attention
 Proper assessment , ofProper assessment , of
 burned surface area andburned surface area and
 fluid requirementfluid requirement
 Consideration of high risk factors andConsideration of high risk factors and
 Appropriate treatmentAppropriate treatment
 RehabilitationRehabilitation
Management of severe burns need a specializedManagement of severe burns need a specialized
BURN UNIT with skilled personnelBURN UNIT with skilled personnel
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31.  Management includesManagement includes
 Admit patient if indicatedAdmit patient if indicated
 Acute resuscitationAcute resuscitation
 CalculateCalculate
 burn surface area,burn surface area,
 degree of burn,degree of burn,
 site of burn and label a surface area diagram onsite of burn and label a surface area diagram on
patient record sheet.patient record sheet.
 Care of burn woundCare of burn wound
 Prevention of infectionPrevention of infection
 Nutrition of burn patientNutrition of burn patient
 Prevent and care of complicationsPrevent and care of complications
 Rehabilitation and physiotherapyRehabilitation and physiotherapy
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32.  Acute resuscitationAcute resuscitation
 Airway maintenanceAirway maintenance
 Large I / V cannulaLarge I / V cannula
 Fluid replacement therapyFluid replacement therapy
 Urinary catheter to monitor urine outputUrinary catheter to monitor urine output
 Central venous pressure lineCentral venous pressure line
 Monitor vital signsMonitor vital signs
 Tetanus toxoidTetanus toxoid
 Pain relief…Pain relief…
……I / V narcotic analgesics Morphine 0.1 mg / kg,I / V narcotic analgesics Morphine 0.1 mg / kg,
Mepridine 1 mg / kg body weight.Mepridine 1 mg / kg body weight.
 Antibiotic prophylaxis in 2Antibiotic prophylaxis in 2ndnd
and 3and 3rdrd
degree burns.degree burns.
BURN PAIN IS SEVEREST TYPE OF PAINBURN PAIN IS SEVEREST TYPE OF PAIN 3232

33.  Classification of severity of burnsClassification of severity of burns
 Major burnsMajor burns……
……need admission to specialized burn unit withneed admission to specialized burn unit with
skilled staffskilled staff
 Moderate burnsModerate burns….….
.need admission to hospital ward.need admission to hospital ward
 Minor burnsMinor burns…………
.treated on out patient basis..treated on out patient basis.
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34.  Major burnsMajor burns……
 ……must be admitted to a highly specialized burn unitmust be admitted to a highly specialized burn unit
 22ndnd
degree more than 25% in adultdegree more than 25% in adult
 22ndnd
degree more than 20 % in infants and elderlydegree more than 20 % in infants and elderly
 33rdrd
degree burns more than 10 %degree burns more than 10 %
 Burns involving primary sites… as face, ears, eyesBurns involving primary sites… as face, ears, eyes
,neck, hands, perineum, feet,neck, hands, perineum, feet
 Patients havingPatients having
 inhalation injuryinhalation injury
 Electricity burnsElectricity burns
 Burns associated with otter injuries…fracture, headBurns associated with otter injuries…fracture, head
injury, chest trauma etcinjury, chest trauma etc
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35.  Moderate burns….Moderate burns….need admission to hospital wardneed admission to hospital ward
 22ndnd
degree burns 15-25% adultsdegree burns 15-25% adults
 22ndnd
degree burns 10-2-% childrendegree burns 10-2-% children
 33rdrd
degree burns 2-10%degree burns 2-10%
 11stst
degree burns 30%degree burns 30%
 No associated injuryNo associated injury
 Minor burns…..Minor burns…..treated as outpatient basistreated as outpatient basis
 22ndnd
degree burns less than 15% adultsdegree burns less than 15% adults
 22ndnd
degree burns less than 10% childrendegree burns less than 10% children
 33rdrd
degree burns less than 2%degree burns less than 2%
 11stst
degree burns less than 30%degree burns less than 30%
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36.  Fluid replacement and maintenance therapyFluid replacement and maintenance therapy
 many formulas……….remember one which you like and easy formany formulas……….remember one which you like and easy for
youyou
 Calculation of fluid requirementCalculation of fluid requirement
 Muir & Barckly formulaMuir & Barckly formula
 Parkland formulaParkland formula
 Evans . formulaEvans . formula
 Baxtar formulaBaxtar formula
 Basic requirement is adequate perfusion andBasic requirement is adequate perfusion and
adequate urine out putadequate urine out put..
 First 48 hours are critical for fluid therapy.First 48 hours are critical for fluid therapy.
 Urine out put is the best guide to know adequateUrine out put is the best guide to know adequate
hydration ………hydration ……… 0.5 ml / kg / hr0.5 ml / kg / hr..
 First fluid to be given is crystalloid solution…..like ringerFirst fluid to be given is crystalloid solution…..like ringer
lactate, dextrose saline etc.lactate, dextrose saline etc.
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37.  Formula for fluid calculationFormula for fluid calculation
 First 24 hrs.First 24 hrs.
 4ml / kg / % of burn = 24 hr requirement.4ml / kg / % of burn = 24 hr requirement.
 Give half in first 8 hrsGive half in first 8 hrs
 Next half in next 16 hrs.Next half in next 16 hrs.
Hour to be calculated from the time of burnHour to be calculated from the time of burn
 Next 24 hrs…….Next 24 hrs…….
 Maintenance 2000ml andMaintenance 2000ml and
 Maintain urine out put 0.5.ml /hr.Maintain urine out put 0.5.ml /hr.
 Plasma is givenPlasma is given
 Blood may be needed in 3Blood may be needed in 3rdrd
degree burns.degree burns.
 Check electrolytesCheck electrolytes
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38.  Care of burn woundCare of burn wound
 Cleaning with sterile salineCleaning with sterile saline
 Apply antibacterial ointments like silverApply antibacterial ointments like silver
sulfadizine or povidine iodine and dressingsulfadizine or povidine iodine and dressing
 Wound dressingsWound dressings
 Exposure methodExposure method……..no cover……..no cover
 Covered methodCovered method………cover with gauze………cover with gauze
 Primary excisionPrimary excision
 Debridement with proteolytic enzymes as …Debridement with proteolytic enzymes as …
travasetravase
 Escharotomy……excision of dead tissueEscharotomy……excision of dead tissue
 Skin graftingSkin grafting
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39.  Nutrition in burn patientNutrition in burn patient
 Metabolic requirement increases 2-4 fold inMetabolic requirement increases 2-4 fold in
burn patientsburn patients
 Proteins are lost in burn oozing fluidProteins are lost in burn oozing fluid
 Give adequate proteins and caloriesGive adequate proteins and calories
 Ant acids and H2 blockers are given toAnt acids and H2 blockers are given to
prevent stress gastric ulcerations.prevent stress gastric ulcerations.
 Vitamins and iron may be givenVitamins and iron may be given
 Nutrition may be givenNutrition may be given
 orally ororally or
 tube feeding ortube feeding or
 parenteral feeding in critically ill and severelyparenteral feeding in critically ill and severely
burned patients.burned patients.
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40.  ComplicationsComplications
 Sepsis of burn wound…..pseudomonasSepsis of burn wound…..pseudomonas
 PneumoniaPneumonia
 Stress ulcers…….gastric and doudenum…calledStress ulcers…….gastric and doudenum…called
....Curlings ulcersCurlings ulcers
 HypoxemiaHypoxemia
 Multi organ failureMulti organ failure
 Acute renal failureAcute renal failure
 Electrolyte disturbancesElectrolyte disturbances
 Respiratory failureRespiratory failure
 ScarsScars
 Keloid formationKeloid formation
 Post burn contracturesPost burn contractures
 Marjolin, s ulcer….squamous cell carcinoma in burnMarjolin, s ulcer….squamous cell carcinoma in burn
scarscar 4040

41. 4141
Post burn contractures

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43.  Rehablitation in burn patientsRehablitation in burn patients
 Physical andPhysical and
 PsychologicalPsychological
 Pressure therapy for hypertrophied scarsPressure therapy for hypertrophied scars
 Active exercises to prevent contracturesActive exercises to prevent contractures
 Plastic surgical procedures for contracturesPlastic surgical procedures for contractures
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44. Plastic surgeryPlastic surgery ……
.is the sub -specialty of surgery devoted.is the sub -specialty of surgery devoted
to cosmetic and functional physicalto cosmetic and functional physical
deformities.deformities.
 Common procedures usedCommon procedures used
 Local relaxing incisionsLocal relaxing incisions
 Skin graftsSkin grafts
 Skin flapsSkin flaps
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45.  Local relaxing incisionsLocal relaxing incisions
 Z- plastyZ- plasty
 V-Y plastyV-Y plasty
 Transposition flapTransposition flap
 Rotation flapRotation flap
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46.  Skin grafts……three typesSkin grafts……three types
 Split or partial thickness……Split or partial thickness……
 .contain epidermis and part of dermis.contain epidermis and part of dermis
 Full thickness……Full thickness……
 ……contain epidermis and full dermiscontain epidermis and full dermis
 Composite ……Composite ……
 .contain epidermis, dermis and sub cutaneous.contain epidermis, dermis and sub cutaneous
tissue , cartilage or bone etc.tissue , cartilage or bone etc.
 ..
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47.  Split thickness or partial thicknessSplit thickness or partial thickness ……
contain epidermis and part of dermis only , thickness …..contain epidermis and part of dermis only , thickness …..0.01-0.0250.01-0.025
inches ,inches ,donner area heals by epithelization from basal skin cellsdonner area heals by epithelization from basal skin cells
Sub classified asSub classified as
 thinthin
 medium andmedium and
 thickthick
 Thigh, buttock and abdomen are common donner sitesThigh, buttock and abdomen are common donner sites
 Advantages.Advantages...
 A large supply of donner areaA large supply of donner area
 Ease o harvesting….(preservation)Ease o harvesting….(preservation)
 Donner site for reuse in 14 daysDonner site for reuse in 14 days
 Decreased primary site scaring and contracturesDecreased primary site scaring and contractures
 Large donner area can be coveredLarge donner area can be covered
 DisadvantagesDisadvantages
 Cosmetic deformity at donner siteCosmetic deformity at donner site
 Decreased durabilityDecreased durability
 HyperpigmentationHyperpigmentation
 Increased secondary contracturesIncreased secondary contractures 4747

48.  Full thicknessFull thickness ……
 contain epidermis and dermis in full.contain epidermis and dermis in full.
 Donner sites…supra clavicular fossa, post auricularDonner sites…supra clavicular fossa, post auricular
site, fore arm and groin. Donner site is closedsite, fore arm and groin. Donner site is closed
primarily.primarily.
 AdvantagesAdvantages
 Cosmetically superiorCosmetically superior
 Decreased secondary contractureDecreased secondary contracture
 Increased durabilityIncreased durability
 DisadvantagesDisadvantages
 Limited doner sitesLimited doner sites
 Large area grafts can not be taken.Large area grafts can not be taken.
 Composite graftsComposite grafts..
 .contain full skin and sub- cutaneous tissue or.contain full skin and sub- cutaneous tissue or
cartilage , or bone etccartilage , or bone etc.. 4848

49.  FlapsFlaps
……are portions of skin and sub cutaneousare portions of skin and sub cutaneous
and or muscle tissue that are movedand or muscle tissue that are moved
from one part of body to other alongfrom one part of body to other along
with their vascular pedicle.with their vascular pedicle.
 Random pattern flapsRandom pattern flaps
 Axial skin flapsAxial skin flaps
 Fascio -cutaneous flapsFascio -cutaneous flaps
 Musculo -cutaneous flapsMusculo -cutaneous flaps
 Expanded tissue flapsExpanded tissue flaps
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50. 5050
Taking skin graft

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Taking skin graft with a dermatome knife

52.  Complications of graftingComplications of grafting
 InfectionInfection
 RejectionRejection
 Underlying seroma formationUnderlying seroma formation
 HyperpigmentationHyperpigmentation
 Contracture formationContracture formation
 Delayed healing of donner siteDelayed healing of donner site
 Improper colour matchImproper colour match
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56. Thank youThank you
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